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0823.4040040 <br /> ere- <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> stateo' arnla Survey Form - Page 1 I1 - 1088149 <br /> CONMB 1811Bt IN—04104) g <br /> Callfomla Imegnted Waay ta Management Board J <br /> Part A-Survey BLUE BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- /m Inspection Type (Fill one) <br /> Site Suffix: ! �^ , 3 (/ •Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��qq�„n/ Cpv,� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name O Inspected B <br /> P Y Inspector <br /> IT_►, SGv,_C.r »�An1;e s I [3I� <br /> — I o / , �,.ct Physical Address <br /> Street <br /> Inspection Date <br /> �T�_[� C•a 9.53_ <br /> .,rty / State Zl� TimeIn <br /> ITTime Out <br /> Business Rep Title 'O PM O PM <br /> Operational Status The Type Business Rola Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill-all that apply) (Fill all that appy) (Fill all that apply) <br /> 0 Active Q Passenger i Generator Q Outdoor <br /> -O Q Closed Q Altered <br /> GPS Latitude �— I j Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude — I I i 1O <br /> Q Planned •OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> I <br /> Q Service Station Q Hauler Q Agriculture Q Shredder fp Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityEN ORCEME' STATUS <br /> 'HAULING AND MANIFEST REQUIREMENTS <br /> Q I Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required/or NOV or FX f) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments WP ' _ n j - <br /> �Gt� e—/— C_�v�--^-fir <br /> �?�a;o�ou,�.�,-�__'u.t.�—�6�1_��(�—ya s�_r,_��iZt�•, J�L��,r -�� <br /> Map <br /> Inspection Form Included:Q <br /> Comments Included:Q — 0 <br /> Bust ass Re is Si tur Phon Num Inspectors Signature Phone Number <br /> INSTRUCTIONS ON BA K <br /> ■ E X A M P LE 62081 <br /> White Yellow <br /> Copy.Operator Pink Copy:LEA ® ■ <br />